HC Deb 27 November 1987 vol 123 cc579-86

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Garel-Jones.]

2.41 pm
Mr. Stuart Holland (Vauxhall)

The House should not adjourn until it has considered the important matter of the closure of wards at St. Thomas's hospital in my constituency. This has major implications for an outstanding teaching hospital, and the need for this matter to be addressed is urgent.

The people of Lambeth receive health care from at least three different health authorities—the West Lambeth health authority, Camberwell health authority and Wandsworth health authority. All have faced and continue to face considerable cuts in spending. All have taken or are taking drastic action to meet the cash limits that have been imposed on them by central Government. However, these cuts are not temporary or short term. They fit in with a clearly denned Government programme of moving money from London health authorities to the provinces, and the two hospitals in the front line of those cuts are King's College and especially St. Thomas's.

Over the past four years, the West Lambeth health authority has made more than £4 million in cuts, which means a 10 per cent, reduction in the number of available beds. Over the next seven years, the West Lambeth health authority will be forced to increase the cuts year by year, and at the end of seven years this will mean cuts of £7 million below current spending. As a result, the authority decided recently that there should be cuts of five acute wards at St. Thomas's hospital—a reduction of nearly 140 in the number of beds. The health authority estimates that, as a result, up to 2,500 people will not receive medical attention. It should be borne in mind that the majority of patients at St. Thomas's hospital are from outside the district.

Lambeth is one of the four most deprived boroughs in the London area, but the patients attending St. Thomas's hospital are coming from outside the area. The results also mean the closure of two community health clinics, the rationalisation of services in two others, the restructuring, as it is called, of the family planning services and reduced and delayed staff recruitment. Although the health authority would like these to be temporary closures, in fact these beds will not be opened again next year since, even with the beds closed, there will still be a shortfall of £1.1 million.

It is inevitable in these circumstances that there should be a reduction of service and patient care. The consequences are quite dire. The choice cannot be made between reductions in quality and volume of the service provided. It is essential that no further reductions should be made in the volume of service, given the considerable pressure on waiting lists.

The costs issue itself is straightforward. For example, the cuts that are being made are essentially on nursing staff. The bed use rate at the moment at St. Thomas's hospital is 98.5 per cent. It has never been higher. Previous bed use rates were lower, which enabled a margin for allowing acute admissions. In practice, reducing available beds by 20 per cent, is equivalent to telling an enterprise running at 98.5 per cent, of capacity that it should from now on run at 80 per cent, of capacity. That raises the unit cost of treating each of the remaining patients. By reducing variable costs, such as pay, one cannot reduce the constant or fixed costs of running a hospital of this size. Therefore, the cuts do not increase efficiency in patient service, even in economic terms. They actually reduce that efficiency.

Over the longer term, the issues facing the hospital and the region are very serious indeed. At the moment more than 2,000 people who are on the waiting list will not be treated in the coming year. That could grow to as high as 2,500. Surgeons at St. Thomas's hospital will in future be doing on average one non-emergency operation per week simply because there will not be sufficient beds for them to use. As a result, surgeons will not be able to train or teach a sufficient number of pupils to ensure that St. Thomas's hospital continues as a teaching hospital. The Nightingale school of nursing is now having to consider a reduction in the number of nurses for training because of ward closures. The indefinite postponement of normal surgery treatment, or cold surgery as it is known, clearly worsens patient care. I am sure that the Minister will be addressing these issues.

For example, an 83-year-old man should be able to receive normal treatment in the urology department at St. Thomas's hospital. The question of bladder retention is a common problem among the elderly. The normal treatment is a catheter to relieve the urine and then simple surgery to correct the condition of acute retention of the bladder is the practice. This man was referred by his general practitioner and had a catheter inserted. He was then sent home, to drip indefinitely. The urology department, with misgivings, has had no option, granted more ward closures and bed reductions. The result is that the patient is distressed, the department is distressed and the quality of patient care is suffering.

The resource allocation working party formula—the RAWP formula—was never intended to reduce allocation in one area and to expand it in other areas. The formula was introduced under a Labour Government to ensure a shift in net resources between regions.

I have made representations to Ministers on this matter. One of the problems with the Government's application of RAWP is precisely that it was based on a population or demographic assumption that the population of inner London would fall. But since 1983 the population in inner London has risen. Therefore, the assumption that was made on long-term expenditure planning for hospitals in inner London is wrong. I said at the time of the abolition of the strategic housing role of the Greater London council that the families that we used to move to outer London would not be moved. This is the heart of the problem. The 10-year regional plan for the London region as a whole assumed that there would be a 15 per cent, decline in hospital admissions in inner London, but the trend since 1983 has been a 2.5 per cent, increase, because the population in the region is increasing.

The reaction to the cuts and the pressure on the hospital by the consultants at St. Thomas's has been amazing. They have agreed to donate 5 per cent, of their pay as a short-term measure. But how effective can that be? I ask the Minister to address this question: will this money be considered additional to own resources raised or generated by the region, as is happening in so many hospitals with the selling of ancillary services such as laundries and car parks? The consultants want to know. Or will such cash raised by or for the health authority simply be taken off its future health allocations? That concerns consultants at St. Thomas's and the West Lambeth health authority.

Frankly, health authorities can do no more. They are now operating at 98.5 per cent, bed occupancy. There are no more savings to be made on support or ancillary services. The cuts have hit the bone. If one takes an overview of the Health Service in the year X, as the Government have done in the past, it can be admitted that some savings could be made. However, if one succeeds with them, simply to cut, cut and cut again would be bad surgery; it is bad economics and it is potentially fatal for patients. The inevitable consequence of the situation at St. Thomas's is that some patients will die because they will not be able to get access to treatment in the hospital itself. The reality is that St. Thomas's has become an emergency hospital. Cold surgery has fallen to insignificant proportions.

Whereas five years ago there was no waiting list at St. Thomas's and doctors could admit patients whenever they wished, there are now more than 500 patients waiting for routine treatment. On average, those patients have been waiting for two years each, and between them they have been waiting for 1,000 years. None of them is likely to be admitted unless there is a drastic reversal of the cuts. The situation is serious and it is well expressed in a letter that I received from a nurse. I shall not cite the name of the nurse, nor was the letter solicited. I have never met her. She says that she is very concerned about the cuts. This is typical of much of the mail that I have received and the discussions that I have had with other nurses at St. Thomas's. She writes: I only see the anguished and anxious faces of patients who are told that they will have to go home a few days early because somebody else needs their bed. The psychological care of a patient is just as important as the physical care that a patient receives; by being sent home early"— this relates to the reduction of turnover time of patients— by being sent home early, with perhaps a few worries and fears unanswered; these patients very often suffer a physical setback associated with their anxiety. All too often these patients have to return to hospital, maybe a week later because of this. In retrospect two admissions cost more money than it would have done to keep that patient in hospital for a few days more on his first admission. I hope that the Minister will address this aspect of the number of patients treated. The Government count the number of patients treated as the number of admissions, even if they are readmissions. The rate of readmission, of course, has risen because of pressure on turnover time in bed occupancy.

The nurse continues: I find it hard to believe that recent cuts suggested in nurses' pay will aid this problem. To my mind it will only serve to worsen it. I am sure you are well aware of the number of nurses leaving the profession because the lack of money outweighs the rewarding nature of the job, and their devotion to it. All too long the Government has manipulated the nurses by playing on their consciences, and using their wish not to strike, as a basis for ignoring their pleas for help. We should be looking to sort this problem out in the future, and without nurses the Health Service will fail. Moreover, without beds patients cannot be served and without further funding the future of St. Thomas's hospital and other major teaching hospitals in inner London will be at risk.

2.56 pm
The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

As this is my fourth appearance at the Dispatch Box this week, the hon. Member for Vauxhall (Mr. Holland) will understand if I do not greet his success in the ballot with my usual cheerful enthusiasm. Nevertheless, I am glad to have this opportunity to deal with the important topic that he has raised in relation to St. Thomas's hospital.

St. Thomas's is one of the country's leading teaching hospitals—perhaps the leading teaching hospital—with a history dating back to mediaeval times. Heavily bombed during the war, in the postwar period it has undertaken extensive rebuilding and expansion. As the new buildings have developed on the site, older and smaller buildings such as the Lambeth hospital, the Royal Waterloo hospital, the Grosvenor hospital, and so on, have been closed and their services moved to the St. Thomas's site. As a result, the work of St. Thomas's now comprises many regional and supraregional specialties. It is also a district general hospital for 170,000 people in the West Lambeth district health authority area and undertakes a great deal of bread and butter work which is also essential for teaching medical, nursing and other staff, including physiotherapists, operating department assistants, and so on.

Whatever difficulties are currently being experienced must be set against that background of growth, expansion and excellence. Any hon. Member would give their eye teeth to have a hospital of the quality of St. Thomas's in their constituency, and it is no insult to the excellent work of the Derbyshire royal infirmary when I say that it would be more than welcome in my area.

The hon. Gentleman referred to a loss of beds. He will acknowledge that that has been happening for a long time, including a period under the Labour Government. Ten years ago, at the peak of movement of services on to the St. Thomas's site, 1,100 beds were available and in use there. Slowly, as bed use has improved and with the growth in day cases, non-invasive techniques of investigation, diagnosis and treatment, many of which have been pioneered at St. Thomas's, the number of beds has fallen steadily to just under 900. Yet the number of patients treated has risen.

Ultimately, we are in business not to make beds but to care for patients. I shall give figures for two years. They have been recorded in exactly the same way, so there is no fudging. They are standard figures. In 1982, the number of in-patient cases treated was 32,800. Last year it was 35,800. The number of day cases in 1982 was 2,900. By last year these had increased nearly four times and leapt to 11,800. That must be the largest increase in day cases in the country. About 350,000 out-patient visits are made each year. That figure has not changed for some years, which perhaps casts a slightly different light on some of the hon. Gentleman's comments.

I will go into the situation with regard to day cases in a little more detail. In trauma and orthopaedics, gynaecology and ophthalmology, the proportion of day cases is among the highest in the country. Indeed, for trauma and orthopaedics it is the highest in the country, with 58 per cent, of all cases done. That helps me give the lie to other districts that say that nothing like that can be done. The figure for gynaecology is 30 per cent., and for ophthalmology 28 per cent.

We look for similar progress in other specialties in the next few years. For example, the percentage of day cases in general surgery is less than 20, and the percentage in general medicine is only eight, which makes the hospital one of the worst in the country. I can see no real reason why the kind of work—or the patient mix—that is being done should be so dramatically different. The turnover interval is good and, generally, the hospital is run extremely efficiently. Length of stay is, however, relatively long, even after standardisation of case mix. That is true across a variety of specialties including, for example, obstetrics, in which it is normal for women to stay for nearly a week, even for normal deliveries, which is now unusual in the rest of the country. That may be partly due to the need to develop community services further. From what I saw when I visited Mawbey Brough health centre in June of this year, the same high standards of buildings—that building cost;£1.25 million—and of care offered are being set out in the community as are being established at St. Thomas's. It is noteworthy that a full service could not be offered at Mawbey Brough for the first 18 months because of considerable resistance from local GPs.

The hon. Gentleman will know of our determination, as set out in this week's White Paper, to improve the work done by GPs and other health professionals in the inner cities and elsewhere. We firmly anticipate that, if successful, that will take the pressure off the acute hospital sector and give better and more effective health care to our people.

Mr. Holland

Is the Minister saying that she hopes that community health care will reduce demand on the hospital? As regards what she has said about the day case rate going up, I believe that that has to do with pressure—because of lack of beds—to give day treatment rather than longer treatment.

Is the Minister aware that the lithotripter, used for dissolving kidney stones, which was introduced with such publicity at St. Thomas's and is a facility serving the nation, cannot be used at anything like its full capacity because the beds are not available, and people are coming from the midlands and being sent home because of that?

Mrs. Currie

The answer to the first part of the hon. Gentleman's question is yes. That is exactly what we expect, because it will provide better and more cost-effective health care. The answer to the second part of his question is that day cases have developed because it is now possible to do them. The use of our facilities is optimised when people are cared for in the most appropriate way possible.

I take the hon. Gentleman's point about the lithotripter, but, as he knows, any new service attracts that sort of interest, and it is much harder for the provision of services to catch up. I know that the district general manager is aware of some of those difficulties.

Many of the patients do not come from the immediate locality. They come from Kent, Sussex, Surrey, south-west London and from anywhere that is accessible to Waterloo station—500 yards walk away. Many of them suffer from the difficult conditions in which St. Thomas's specialises, but many do not. The conditions are routine, and one of the key elements of policy for many years under many Governments has been to try to ensure that such people can receive their services—including their hospital services—locally, so that they do not have to come into London to overburden hospitals here. An informed guess would suggest that 10 to 20 per cent, of the patients at St. Thomas's might well be treated at a hospital closer to home, with all the associated improvements that could result in follow-up. The White Paper will charge family practitioner committees in future with a more thorough examination of GPs' referral systems and referral rates, with a view to picking up those who perhaps refer too readily to the nearest hospital—or, in this case, to one of the more distant hospitals. They will also try to pick up GPs who do not refer enough. We hope for progress in that direction before too long.

St. Thomas's is popular with doctors and patients alike, not only because of the sheer quality of the care given but because staff have managed to create there a remarkable atmosphere which is at once friendly, good-natured and professional. That was my impression when I opened the emergency delivery suite there in May, and I was not in the least surprised when my nephew chose to go there to train as a doctor.

The present difficulties should be seen in this context. When the Labour Government started to review the allocation of financial resources—when the RAWP system was first set up 10 years ago by the noble Lord Ennals and the right hon. Member for Plymouth, Devonport (Dr. Owen)—it soon became apparent that London had lost 2.5 million people since the war, and it now houses a much smaller proportion of the British population than it used to. Nevertheless, London was still taking the lion's share of health spending. Since then, therefore, spending efforts have shifted deliberately from the south to the north and, within the south, from London to the home counties.

The hon. Member for Vauxhall mentioned a 10-year plan, developed in 1984, that postulated that London hospitals should lose 1,500 acute beds over the 10-year period and should instead build up the community services that have already been mentioned, and services to geriatrics, the mentally ill and the mentally handicapped. It should be remembered that many of those patients have to go a long way out of Lambeth, including as far as Darenth Park in Kent.

What has happened is that, in the three years since 1984, 1,100 acute beds in London have been lost. In fact, as Londoners tend to do, they have moved a lot faster on this than anyone expected. There has been a growth in other services as well. To be fair, this bed loss has sometimes simply entailed changing the label on the bed from acute to geriatric, often with the same patient in the bed. Nevertheless, inner London is still left with twice the number of acute beds for its population as the rest of the country and two and a half times the proportion for outer London—where the population of inner London has moved.

The district profile shows that West Lambeth health authority had a £73 million initial cash allocation in 1985.86 and £81 million for 1987.88. Those figures include the cash released from cost improvements such as tendering for hotel services, which is continuing; receipts from land sales on top are also expected and the district has some bright ideas for raising revenue, as mentioned by the hon. Member for Vauxhall.

My message to the consultants is go ahead. We shall ensure, especially as a result of today's discussion, that the regional health authority understands that it is our view that the consultants must have some incentives to proceed in the way that has been suggested. We intend to change the law to make it easier for health authorities to practise income generation of the kind that they have been exploring.

The district has endeavoured to keep its spending, especially on agency nurses, under control. As a result, last year, it found it harder to recruit the specialised staff that it needs. Therefore, in the first six months of this financial year a determined recruitment drive was instituted, especially in Ireland. That drive brought in the staff. A review of the budget in September showed that, as a result, the DHA expected to be overspent by some —2.5 million by the end of the financial year. Next year the overspend could be about the same. The details and the actions taken have been rehearsed by the hon. Member for Vauxhall.

All our health authorities have the same statutory obligations not to overspend on budget. This morning I had the benefit of a long discussion with the district general manager of the West Lambeth health authority, Dr. Stephen Jenkins. He is a consultant and I greatly admire the approach that he and his colleagues are taking. I am sure that they are well apprised of the difficulties. They are using both old-fashioned management skills, such as looking at the performance indicators—the district general manager could reel them off quicker than I can—and a lot of modern imagination and initiative to help solve the problems. Some of the actions proposed will require action by Ministers. Indeed, the proposed disposal of the south London site, which has been empty for two years, is on Ministers' desks at present.

Mr. Holland

The Minister will appreciate that I have made strong representations to her about the south London site. I believe that that site should be available for medical or medical-related use, including people moving from Tooting Bee, and nurses' accommodation. Such accommodation is desperately important to the West Lambeth health authority. The figures that I gave regarding a waiting list of 1,000—500 patients for two years ahead—concerns only the neurology department at St. Thomas's. There was no waiting list five years ago. In her discussions, has the Minister been able to address the crisis situation that St. Thomas's now faces?

Mrs. Currie

I will not make a decision right now about the south London site, but we are close to making an announcement. I put it to the hon. Gentleman that we could go from one extreme to the other with the disposal of that site. We could use that site entirely for medical activity, which would involve substantial expansion and need new money. That would make the problems of West Lambeth health authority and St. Thomas's much worse. We could go entirely to the other extreme and dispose of it entirely. That would raise a large sum of money, but would lose the site for Health Service purposes. Perhaps we may find some highly acceptable compromise that will produce a substantial chunk of cash—it is an extremely valuable site—and at the same time help solve some of the problems to which the hon. Gentleman refers. I shall make an announcement shortly.

As I have said, at least some of the problems with the waiting lists—not all by any means—are partly attributable to the fact that some patients could well be treated somewhere else. Patients are, and continue to be, the responsibility of their own general practitioners. I recognise that that is not a problem that we can resolve overnight.

Some of the proposals that no doubt would assist St. Thomas's and the West Lambeth district health authority may well have to come to Ministers before long through the statutory procedure. I hope that the hon. Gentleman will understand if I cannot give any more details than that. Any permanent changes must go through the statutory consultation procedure first. We shall ensure that all the views expressed about the changes and possible future changes are taken into account and that decisions are taken with the interest of patients and local people very much at heart.

St. Thomas's has an outstanding past. It continues to provide an outstanding service to people in London and beyond. It will no doubt continue for centuries to come to dominate our physical view here at Westminster and also the medical world at large. I sincerely hope that its current problems are only temporary.

Question put and agreed to.

Adjourned accordingly at ten minutes past Three o'clock.